Mon July 15, 2013

Patients Seek A Different Approach To Hip Replacement Surgery

Michael Pagliaro, left, laughs with Paul Scattaretico at the Muzic Store Inc. in Dobbs Ferry, N.Y., as Pagliaro picks up instruments for his rental business. Before Pagliaro had a hip replacement, pain made it difficult to work.

Michael Pagliaro pedals on a stationary bike in the warehouse of his business in Dobbs Ferry, N.Y. Working out is fun again now that his hip doesn't hurt.

Maggie StarbardNPR

Every year more than a quarter of a million Americans have total hip replacement surgery. It's almost always a successful operation that frees patients from what's often described as disabling pain.

But in recent years, there's been lots of discussion on the Internet about "anterior approach" hip replacement, a surgical technique that's different than the standard procedure. It's one that proponents say can lead to quicker recovery, three to four weeks compared to six to eight weeks for typical surgery.

Some people have been willing to give it a try, even though there's no conclusive research showing it's better than other approaches.

Take the case of Michael Pagliaro, 52, who lives in Scarsdale, N.Y., and runs a company that rents and sells musical instruments to schools. He's an active man, has a personal trainer, rides horses and works hard. So when his hip started hurting last year, he says, he "got very sad."

When he walked, the pain from his hip made his knee buckle. He was diagnosed with avascular necrosis – blood was not adequately flowing to the hip joint, causing the bone to degenerate. Doctors told him he needed surgery to replace the damaged bone and cartilage in his hip with an artificial ball and socket.

"He explained that it's a very eventful surgery, that I'd be incapacitated for six weeks, have to sleep with a pillow between my legs, can't do this, can't do that," says Pagliaro. That, he says, was a "real buzz kill."

Overwhelmed by what sounded like a difficult recovery period, Pagliaro searched for alternatives. He tried physical therapy and avoided certain activities. But the pain persisted, and he came to realize that surgery was inevitable. When he searched online, he discovered a surgical approach to hip replacement that sounded a lot less overwhelming than what the doctor described.

Soon Pagliaro found his way to Michael Alexiades, an orthopedic surgeon at the Hospital for Special Surgery in New York City. Alexiades is one of the surgeons responsible for the recent resurgence of interest in what's called the anterior approach. In this case, surgeons enter the hip joint from the front of the thigh, rather than the more conventional posterior approach, from the back.

"When I did the anterior approach, it was dramatic how quickly the patients were getting up and walking and how quickly they were ready to leave the hospital," says Alexiades. "They were leaving the hospital a lot quicker than my posterior approach patients." He says the anterior approach cut recovery time in half for some patients.

The fast recovery may have to do with less muscle being cut and stretched during the anterior procedure, Alexiades says. Patients also reported less pain with this approach. Michael Pagliaro was sold, had the surgery and was out of the hospital in two days. "I was at home having lunch at my favorite restaurant with my friend and my wife; everyone said it was amazing. 'Didn't you just, eh eh eh......?'"

Pagliaro had a cane for support but didn't really need it. The following Monday, just one week after surgery, he was back on the job. And not even taking pain medication, just aspirin as needed. (But he's still not back to riding horses.)

According to Alexiades, "I would think probably nine out of 10 people who need a straightforward total hip replacement for the first time are good candidates for an anterior approach."

But there are patients who aren't good candidates. That includes those with major bone deformities since birth or those getting a 're-do,' a second or third replacement surgery, or patients who are obese.

In these more complicated cases, surgeons can actually see better using the posterior technique. It also takes less time and, according to orthopedic surgeon Thomas Sculco, also at the Hospital for Special Surgery, offers other benefits. "There's less blood loss, no need for X-ray during procedure, and in my experience, the recovery is as quick as with the anterior approach," he says.

In over 35 years of practice, Sculco has performed over 10,000 hip replacements and like most surgeons today, relies on the posterior approach for hip replacements for most of his patients. "I'm slow to change to something else unless I can see some real advantage to changing," he says. "And I really don't see any advantage to changing in this case, either in terms of outcomes or in terms of recovery."

Patients looking for clinical trials that directly compare complication rates, pain, and recovery time for the two techniques are going to be frustrated. There aren't any. A 2004 review of studies on both techniques found there wasn't enough evidence to say which was better.

There is a lot of research on the posterior approach, which has been used since the 1960s, but much less on the anterior approach. Small trials that have been done on the anterior procedure have found a higher rate of bone fractures during surgery. But it's unclear if those results come from the fact that many surgeons aren't experienced with the procedure or from other issues.

There's also no data on how often the anterior approach is performed. The American Academy of Orthopedic Surgeons says that about 20 percent of their members know how to perform the surgery.

Critics say the increased interest in anterior approach surgery may be more due to marketing from doctors, hospitals and companies that sell specialized operating tables and other gear rather than any benefits to patients.

Clinical trials comparing the two methods are underway at the Mayo Clinic and at the Hospital for Special Surgery, but it may well be five years before that data is available.

In the meantime, doctors says it's important to look at the big picture.

Claims that less muscle is cut when entering from the front of the thigh for the anterior approach isn't true for most patients, Pagnano says. "Small muscles often end up being cut in both procedures," he says, as surgeons work to stretch and move muscles in order to get into the joint.

So why all the Internet hype about the anterior approach? Something that sounds new and different is appealing, says Pagnano, and many procedures are promoted on the Web as new. That doesn't necessarily make them better, he adds.

"What patients really need is knowledge," says Pagnano, "the Internet is great for providing information, but it lacks a context in which to interpret that."

How does a patient sift through all the information and make an informed decision? Dr. Joshua Jacobs, president of the American Academy of Orthopedic Surgeons, says patients should investigate information on a reputable website like the academy's website, which can also help them find a surgeon.

One key question to ask an orthopedic surgeon is about the number of times he or she performs this procedure in a year. Like most things in medicine, practice makes perfect. And being expert, says Jacobs, means performing a surgery at least 100 times a year.

Once patients have found a doctor, they should talk the physician which technique is best, given the patient's history and preferences.

"All approaches to hip replacement have gotten less invasive over time because of our understanding of anatomy, more sophisticated surgical tools and instruments that allow better access with a smaller incision," he says. "All the surgical approaches are less invasive than they were seven to 10 years ago."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

DAVID GREENE, HOST:

On this Monday, it's MORNING EDITION from NPR News. I'm David Greene.

RENEE MONTAGNE, HOST:

And I'm Renee Montagne.

Today in Your Health: hip surgery. Every year, more than a quarter of a million Americans have a total hip replacement, freeing them from, often, disabling pain. The surgery is extremely successful with only rare complications. In recent years, an unconventional surgical technique has been attracting a lot of interest on the Internet. Proponents say it leads to quicker patient recovery.

NPR's Patti Neighmond takes a closer look.

PATTI NEIGHMOND, BYLINE: Michael Pagliaro runs a musical instrument company that refurbishes, rents and sells musical instruments to schools in New York and Connecticut.

MICHAEL PAGLIARO: You name it, we fix it. Our head technician, Gary Manzano, is over here. He actually has to check a saxophone so maybe we can see if he's got it down pat.

(SOUNDBITE OF MUSIC)

NEIGHMOND: Pagliaro is a very active man. He has a personal trainer, rides horses and works hard.

PAGLIARO: We have about 10,000 clients and it's a busy time for me most of the time. So when my hip started hurting, I started getting very sad. I had a lot to do and it was hard to get it done.

NEIGHMOND: Pagliaro was 51 at the time. When he walked, the pain from his hip made his knee buckle. He was diagnosed with a form of severe arthritis. Doctors told him he needed surgery to replace the damaged bone and cartilage in his hip, with an artificial ball and socket made of metal, plastic or ceramics.

PAGLIARO: And he explained that it's a very eventful surgery. He said you're going to be incapacitated for probably six weeks. You can't do this. You can't do that. And that was a real, you know, a real buzz kill.

NEIGHMOND: The worst case scenario. Pagliaro searched for alternatives. He tried physical therapy, avoided certain activities, but the pain persisted. He knew surgery was inevitable. He surfed the Internet and stumbled onto a relatively new surgical approach to hip replacement that sounded a lot less overwhelming than what the doctor described. It turned out he had some friends who had this procedure.

PAGLIARO: They said its a small cut. You're up and at 'em pretty immediately. And you're back to work and you're back to your life very quickly.

NEIGHMOND: So Pagliaro found his way to Dr. Michael Alexiade, an orthopedic surgeon at the Hospital for Special Surgery in New York City. Alexiade is one of the pioneers of what's called the Anterior Approach, where doctors enter the hip joint from the front of the thigh rather than the more conventional posterior approach, where they enter from the back of the thigh.

DR. MICHAEL ALEXIADE: When I did the anterior approach it was dramatic how quickly the patients were getting up and walking, and how quickly they were ready to leave the hospital. So they were leaving the hospital a lot quicker than my posterior approach patients.

NEIGHMOND: Alexiades says the fast recovery may have to do with less muscle being cut and stretched during the anterior procedure. Patients also reported less pain with this approach.

Michael Pagliaro was sold.

PAGLIARO: The surgery was on time. He said it was going to an hour and a half, and it was under one hour. And I had it at 11 o'clock. And at 4 o'clock, I was walking.

NEIGHMOND: Two days later, he was home.

PAGLIARO: I was home Wednesday, 12:30, having lunch at my favorite restaurant with a friend of mine and my wife. I said this is amazing. Everybody was like, Wow, didn't you just - weren't you just - what - it uh-uh.

NEIGHMOND: Pagliaro had a cane for support but really didn't need it. The following Monday, one week after surgery, he was back on the job and not even taking pain medication - just aspirin as needed.

Dr. Alexiade.

ALEXIADE: Probably nine-out-of-10 people, who need a straightforward total hip replacement for the first time, are good candidates for an anterior approach.

NEIGHMOND: But there are patients who aren't good candidates: those with major bone deformities since birth; or those getting a redo - a second or third replacement surgery; or patients who are obese. In these more complicated cases, surgeons can see better with the posterior technique.

It also takes less time, says surgeon Thomas Sculco, also at the Hospital for Special Surgery. And it offers other benefits.

DR. THOMAS SCULCO: There's less blood loss. There is not a need for X-ray fluoroscopy during procedure. And in my experience, the recovery is as quick as with an anterior approach.

NEIGHMOND: Over 35 years of practice, Sculco hass done over 10,000 hip replacements, and relies on the posterior approach for most of his patients.

SCULCO: I'm slow to change to something else unless I can see some real advantage to changing. And I really don't see real advantage to changing in this case, either in terms of outcomes, or in terms of recovery.

NEIGHMOND: And, despite anecdotal reports from some patients and doctors, there is simply no evidence - no randomized clinical trials - proving one approach superior to the other. Today, like Sculco, most surgeons still rely - on the posterior method.

(SOUNDBITE OF WALKING)

EILEEN COCCO: Yeah, mariachis would be fun.

NEIGHMOND: Eileen Cocco walks in her neighborhood outside Chicago with her much younger boyfriend. Cocco is 77 years old.

COCCO: I'm the mother of seven children. That might have helped wear my hips out, because I had seven in 10 years before I was 29.

NEIGHMOND: And after seven children, Cocco was runner up for Miss Illinois.

COCCO: So I'm pretty proud of that.

NEIGHMOND: Cocco also worked at a retail store. Twenty-five years in high heels on cement floors, she says, probably didn't help her hips much either.

By the time she needed surgery, her hip pain was so severe she quickly agreed. Both hips were replaced using the posterior surgical method. Cocco says her recovery was marvelous.

COCCO: Well, they get you up right away to sit on the side of the bed, and I'm like, you've got to be kidding.

(LAUGHTER)

COCCO: And the next morning they got me up and, and they said, you want to go home? I'm like, yes. OK. Well, you have to do 12 stairs - 12 stairs, I did - up and down.

NEIGHMOND: Like Michael Pagliaro, Cocco was out of the hospital in two days, and back to normal activities in two weeks.

COCCO: I didn't miss a thing.

NEIGHMOND: Surgeon Mark Pagnano, with the Mayo Clinic, says that today most healthy patients recover quickly no matter which surgical technique is used. He adds that claims of less muscle being cut when entering from the front of the thigh isn't really true for most patients. Small muscles often end up being cut in both procedures, he says, as surgeons work to stretch and move muscles in order to get to the joint.

So why all the Internet hype about the anterior approach? New is appealing, says Pagnano. And, in milliseconds, people can find tons of information about any type of surgery.

DR. MARK PAGNANO: What patients really need is knowledge. The Internet is great for providing information, but it lacks a context in which to interpret that. And without the context all you have is bits and pieces of data, but you don't have a clear or cogent way to put that together to really help you make an informed decision.

NEIGHMOND: Dr. Joshua Jacobs is president of the American Academy of Orthopedic Surgeons. He says in order to make an informed decision patients should talk with their surgeon about which technique is best for them and understand that all techniques have gotten better.

DR. JOSHUA JACOBS: All approaches to hip replacement have gotten less invasive over time, because of our understanding of the anatomy; because of surgical tools that allow us to get better access with a smaller incision. So it's not just that anterior approach can be less invasive; all of the approaches that are now available are less invasive than they were, you know, seven to 10 years ago.

NEIGHMOND: And, he says, remember to ask your surgeon how many operations they perform in a year. Like most things in medicine, practice makes perfect. And being expert, says Jacobs, means doing at least 100 surgeries - either posterior or anterior - a year.